Transforming Turkey's Health System--Lessons for Universal Coverage.

n engl j med 373;14 nejm.org october 1, 2015 1285 coverage and notable improvements in outcomes and equity. Health insurance was introduced in Turkey in 1945, at first covering blue-collar workers and later other groups. From 1960 onward, Turkey’s 5-year development plans included universal health coverage as an objective; a new constitution in 1982 guaranteed rights to health insurance and health services; and a 1987 Basic Law on Health aimed to operationalize these rights. But the law wasn’t implemented, universal coverage failed to materialize, and the poor and unemployed remained without effective coverage. Although the “Green Card” scheme was introduced in 1992 to cover lowincome households, it wasn’t integrated with existing insurance schemes and lacked a system for identifying potential beneficiaries; moreover, it provided limited financial assistance for inpatient care and none for outpatient consultations, diagnostic tests, or medicines; uptake was therefore low. Battling economic instability, rampant inflation, rising unemployment, and a dissatisfied public, successive coalition governments between 1990 and 2002 did not prioritize health coverage and services. The Turkish health system faced insufficient and inequitable financing, a shortage and inequitable distribution of physical infrastructure and human resources, disparate health outcomes, and public dissatisfaction. Then, in 2002, a new political party won a parliamentary majority and created a government committed to economic and social reforms. In 2003, it introduced a Health Transformation Program (HTP) that aimed to improve public health, provide health insurance for all citizens, expand access to care, and develop a patient-centered system that could address health inequities and improve outcomes, especially for women and children.1 The 2003 Directive on Patient Rights defined citizens’ rights to health insurance and choice of health care providers. It codified providers’ obligations regarding information provision, confidentiality, and patient consent for interventions and established systems for citizens to express their views about health services.2 Health reforms introduced between 2003 and 2010 separated policymaking, regulatory, financing, and service-provision roles: the Ministry of Health would focus on policy and strategy development, while other agencies oversaw public health and delivery of personal health services. The Social Security Institution was established as a single payer, pooling both risk and funds from contributory health insurance and INTERNATIONAL HEALTH CARE SYSTEMS